Advocacy for Oversight of Medicare Advantage in Puerto Rico
The clinical laboratory association in Puerto Rico is advocating for enhanced oversight of Medicare Advantage expenditures following a federal projection that indicates a substantial funding increment for the island's plans by 2027. This increase is set at over $561 million, benefiting approximately 679,000 Medicare Advantage beneficiaries in Puerto Rico.
The President of the Puerto Rico Clinical Laboratories Association (ALCPR), Felipe Cintrón Zayas, acknowledged the efforts of Governor Jenniffer González Colón and Resident Commissioner Pablo José Hernández Rivera, alongside a coalition from the health sector, in securing a 4.01% rate increase for Medicare Advantage plans in Puerto Rico. This increase surpasses the national average, as noted by local officials.
The call for improved oversight comes as the ALCPR is engaged in ongoing litigation concerning reimbursement cuts imposed unilaterally by an insurer. A recent decision by the U.S. District Court in Puerto Rico has moved the association's lawsuit against Triple-S Advantage and Triple-S Salud to the jurisdiction of Puerto Rico's state courts. The ALCPR claims that the companies enforced payment reductions up to 25% on labs providing services to Medicare Advantage members.
Laboratories in the region are experiencing significant financial pressure due to insurers expanding into clinic operations and developing in-house lab services, while also securing reduced payments to independent service providers. Felipe Cintrón Zayas emphasized the necessity for the increased funds to enhance access, ensure compliance with federal regulations, and guarantee equitable remuneration, rather than inflate profit margins for insurers at the expense of the laboratory network supporting patient care.
The ALCPR has recommended rigorous auditing of the Medical Loss Ratio reports for Medicare Advantage plans in 2027, aimed at assuring that federal funds are allocated to medical care, including provider payments, instead of administrative expenses. According to federal guidelines, a minimum of 85% of certain revenues must be spent on medical care and quality improvements.
Furthermore, Cintrón Zayas has called upon the U.S. Department of Health and Human Services' Office of the Inspector General to incorporate Puerto Rico in Medicare Advantage compliance audits. He referred to the agency’s updated compliance program guidance from February, marking its first significant update since 1999. The laboratory association argues that a considerable portion of medical decisions rely on lab tests, and persistent payment cuts could jeopardize patient access to necessary diagnostics.
In legal proceedings, Triple-S contended the case should be adjudicated in federal court due to its involvement with Medicare Part C requirements. However, the ALCPR maintains that Puerto Rico's contract law prohibits unilateral amendments in adhesion contracts, advocating for local judicial resolution. "The court's decision allows the determination of reimbursement rate modifications to proceed appropriately within the Puerto Rican legal framework," stated Cintrón Zayas. The core of the dispute involves Triple-S’s adjustment of its payment structure from a percentage of the 2016 Medicare fee schedule to the 2025 schedule, which the ALCPR claims fails to cover service costs.